Predicting Outcomes in Whiplash

Introduction

Whiplash is an acceleration-deceleration mechanism of energy transfer to the neck. [1] It can be caused by rear-end or side-impact motor vehicle collisions, but can also occur in sports (diving snowboarding) and other types of falls. Impact may cause bone or soft tissue injury, affecting ligaments to muscles and nerves and may lead to other clinical manifestations known as whiplash-associated disease (WAD). [2] [3] WAD is a term used to describe the set of symptoms that follow a whiplash injury. [4] It is considered the most common outcome after a non-catastrophic motor vehicle accident Accidents[5] WAD symptoms range from neck pain, headache, radicular symptoms, stiffness and tenderness to loss of motor function and mental and stress responses. [4][6][7] Physiological changes and tissue damage are often undetectable. [8][9] Usually patients recover within 3 days Months after whiplash, but ½ of patients with acute WAD go on to develop chronic pain and/or disability. [3] To learn more about WAD, you can click on the following link: Whiplash Associated Disorders

Early identification of individuals at risk of long-term pain and disability will help clinicians use the correct resources in prevention and treatment. [10] This topic is under constant research and therapists should keep abreast of the latest predictive research factor. [10]

[11]

Factors that predict poor outcomes

High levels of initial pain and high scores on the Neck Disability Index were found to be the strongest predictors of pain and disability after 6 months. [10] Other strong predictors include cold hyperalgesia, older age, and acute posttraumatic stress. [12]

1. High level of initial pain

A pain level of 5.5/10 on the visual analogue scale was considered high [10]. High levels of initial pain have been found to be strong predictors of adverse long-term outcomes [3] [10]

It is an easy-to-use scale for therapists and doctors to measure initial pain and pain levels during activities of daily living or work. [13]

A 2017 meta-review also suggested a possible link between initial pain levels and anxiety and outcomes after acute whiplash. [14]

2. Characteristics of pain

Presence of neuropathic pain – listen to the description the patient used in the history taking – the burning shock in its own area felt extra tender. Allodynia.

Neck Disability Index (NDI) [10]

• A 10-item questionnaire completed by the patient asks the patient to rate activities of daily living such as personal care reading driving concentration pain intensity weight lifting sleep sleep recreation and headache on a scale of 0-5 indicating disability for these activities. [4]
• Along with pain intensity, it is considered a very strong predictor of adverse outcomes in chronic pain and disability
• greater than 14.5/50 [10]

3. Psychological factors

Catastrophizing

• “Catastrophization refers to an excessively negative tendency to noxious stimuli”[15]
• It is considered multidimensional and includes the following:[16]
  • Meditation – when a person cannot stop thinking about the pain, especially the magnitude of the pain
  • Zoom – Terrible Thoughts Serious Things Could Happen
  • Helplessness – a feeling that there is nothing that can be done to alleviate the pain
• These patients generally have a negative perception of pain. They have passive coping skills such as lying down taking pain medication and expecting the doctor to fix it. Sometimes they even seem sick. Poor recovery expectations and passive coping are some of the most consistent features of. predict outcome in chronic whiplash symptoms.[17]
• “The most robust and reliable psychological indicator of pain experience” [2] .
• The Pain Catastrophizing Scale is a 13-item questionnaire for patients to rate how often they experience certain thoughts and feelings when they experience pain. [2] .
• High risk is considered high risk [4].
• When risk to patient is reduced the patient (acute/chronic) will reduce acute pain and disability [4].

Fear of movement

• The TAMPTA scale of kinesiophobia (TSK) is a questionnaire consisting of 17 items.It measures fear of (re)injury due to motion. Scores range from 17 to 68 with a score of 37 being considered high. [4] .
• Ask the patient what concerns they have about what fears they have. Accordingly, e.g. do they think their spines are weak and fragile? What movements or exercises are they avoiding?

Post traumatic stress reaction

High levels of pain combined with posttraumatic stress disorder are considered a strong predictor of a positive outcome following whiplash.

• It occurs in about 25% of people who are whipped in car accidents [4].
• Characterized by 3 major symptom groups (clusters):[18]
  • Re-experiencing symptoms – intrusive thoughts about the accident in daytime nightmares
  • Symptom avoidance – social withdrawal, avoiding any stimuli or thoughts that remind one of the accident
  • Hyperarousal state – Hypervigilance Nervousness Irritability High respiratory rate
• Ask patients how often they think about the accident. Do they keep telling you about the accident?
• Measured by Incident Impact Scale (IES). It is a 15-item questionnaire and post-traumatic stress screen as it measures current subjective stress about a specific life event. [19]
• The revised EIS includes questions about hyperarousal. It is called the Event Impact Scale-Revised (IES)-R and is a 22-item questionnaire. Link to revised scale: (IES)-R
• IES should only be done 6 weeks after the injury because it is normal to have these intrusive thoughts before then.

Perceptions of injustice have been shown to be predictors of long-term disability and pain following whiplash injuries [18]

4. Physical factors

Widespread tenderness in an area not affected by the injury

• front of the shins
• Generalized hypersensitivity – test with blunt stress [20]

Altered cold pain threshold (hyperalgesia) – associated with pain and disability 6 months after whiplash. [12]

• Feels like burning when touched with metal at 15-20 degrees Celsius
• If the cold pain threshold is 1 degree lower than normal, the person is likely to experience moderate/severe symptoms in the long run [12]
• Considered a strong predictor of sensation as well as impaired sympathetic vasoconstriction [12]
• In individuals with persistent moderate to severe pain/disability, thermal hyperalgesia (heat/cold) develops shortly after whiplash injury [20]
• May indicate peripheral nerve injury [12] “changes in the central regulation of pain” [20] or changes in the sympathetic nervous system [20].

Positive upper extremity tension test 1 (ULTT1) or brachial plexus provocation test [20]

• Positive or exacerbated responses shortly after whiplash in those individuals with persistent moderate to severe pain/disability
• In patients with chronic WAD, decreased bilateral elbow extension indicates motor and sensory changes due to central sensitization
• For more information on this test, click on the Neurodynamic Assessment link

Additional factors to consider

Weak predictor of risk – can aid in prognostic and intervention decisions, but cannot show causality [10]

• Female gender – a robust predictor of risk [10]
• Low back pain incident reporting and postmortem evaluation [10]

Poor predictors

• Changes in cervical spine range of motion and neck muscle activity after whiplash were not considered to be significant predictors of long-term pain and disability. [3]
• Incident parameters recalled by patients were not considered predictors of recovery. More data from vehicles may change in the future as technology improves. [10]
• Past medical history [10]

Management

Some research exists on beneficial interventions for different stages of whiplash, but further research is definitely needed. Acute (<2 weeks) Subacute (2-12 weeks) Chronic (>12 weeks). [21] Exercise and therapy including mobilization are the most studied and appear to be superior Treatment of acute and chronic WAD. [21] Moderate to aggressive mobilization and exercise should be avoided during the acute and subacute phases. [21] Interdisciplinary treatment has also been widely studied, and the effect of psychological counseling combined with physical therapy is better than that of Physiotherapy alone. [twenty one]

General treatment strategies are discussed below.

Acute Phase

Studies have shown that patients experience rapid improvement in symptoms within the first 90 days after injury, but then a plateau of recovery occurs. A significant number of patients experience ongoing pain and disability. This means that the first 3 months after injury are critical for management these patients. [twenty two]

An interdisciplinary team approach is recommended for patients in the intermediate-to-high risk range for chronic pain and disability after whiplash.

• This will include physical therapy to restore ROM pain management and medication for adequate pain relief, as well as psychotherapy specifically targeting the patient’s post-traumatic stress response. [12]

Manage initial pain

• Reduce pain experience
• Neuropathic Pain—Manual Therapy Aerobic Exercise Localized movement relieves pain experience. neuropathy drugs

Advice/education [21] Oral and video education may be more effective than distributing pamphlets for patients to read. [twenty three]

Catastrophization

• Interventions will vary according to the goals set for that patient [15]
  • If return to work is the goal, the focus should be on graded activities and engagement
  • If reducing pain levels is the goal, then monitoring thoughts and reframing cognitive behavior will be the goal
• Should be combined with other management techniques [15]
• Cognitive Reframing – Listing/recording/discussing pain-related thoughts. Elicit negative thoughts and make them aware of them. Do you find this helpful? What’s the use of that? Replace it with positive thoughts.

Fear of exercise and re-injury – control/support exposure to feared activities. Support and guide them.

Post traumatic stress

• Early specific treatments for posttraumatic stress are more effective than general cognitive-behavioral treatments. [12]
• PTS Responses – Outside PT Domain/Expertise (Clinical Psychologist CBT EMDR – Eye Movement Desensitization Reprocessing)

Physical symptoms

• Gentle desensitization techniques for extensive tenderness Exposure to slow and graded aerobic exercise.
• Mobilization programs include activities aimed at improving or maintaining mobility [23]
• There is strong evidence that active mobility is associated with reduced pain, and some evidence suggests that it may improve range of motion in acute WAD. [twenty three]
• Neck-specific exercises – Physical therapist-directed neck-specific exercises have been shown to reduce disability after 3 months compared to physical exercise prescriptions [24]
  • Cervical range of motion improves with physical therapy guidance and a self-management program of low-load exercise, but only physical therapy approaches improve motor control. [19]
  • Active mobilisation [21]

Electromagnetic field therapy – some limited research suggests this is effective [21]

Treatments deemed not effective

• Soft collar fixation – may hinder recovery [21]
• Laser acupuncture[21]
• Education alone[21]
• Exercise programs that focus purely on strength and endurance, not flexibility [23]

Medication

• There is some evidence that methylprednisolone infusions are effective in acute WAD [23]
• NSAIDs may help reduce inflammation and pain in the acute phase, but they should not be used long-term due to their side effects. [25]
• No studies have shown a role for muscle relaxants, antidepressants, or anticonvulsants, and according to general consensus opioids should be avoided. [25]

Sub-acute Phase

Limited studies focus on this phase.

Multidisciplinary therapy is most effective by manipulating the joints showing some benefit.

Chronic Phase

Exercises performed by a physical therapist can produce meaningful changes in the symptoms of a patient with chronic post whiplash pain.[19] Exercise appears to be the most effective non-invasive treatment in this phase. [21] When treating patients with chronic whiplash, attention should be paid to. the following: [13]

• improving impaired bodily movements and functions
• working on the psychosocial abilities and functions of the patient

Manual therapy – using joints has shown to be helpful as well as myofeedback training. [21] Compared an exercise approach using multiple models with patient self-management. Both groups improved in their NDI scores but more so in the exercise group. Also the gymnastics team significantly improved NPI scores. [19] The following treatments were included in the exercise group:[19]

• Specific low-load exercises for the neck flexors and extensors, as well as the scapular and postural muscles.
• kinesthetic exercises
• low velocity manual therapy techniques
• Ergonomic ADL and work environment education
• assurance

Physiotherapy exacerbates the condition in some patients with chronic WAD, so the authors of this study opted for only low-load interventions. [19] However, when patients have extensive mechanical and thermal hypersensitivity, physical therapy should not be the only treatment these patients receive. [19]

It has been shown that the psychological component of chronic WAD may be due to persistent pain and disability. The patient’s psychological problems worsened a week after the accident, related to decreased neck movement. Thus, the longer the symptoms have been present, the greater the psychological impact Psychological factors improve as pain and disability improve. [4]

Resources

Whiplash-Related Disorders Pain Catastrophization Scale – PhysiopediaMyrtveit SM Skogen JC Petrie KJ Wilhelmsen I Wenzel HG Sivertsen B. Factors Associated with Irrecoverable Whiplash. Nord-Trøndelag Health Study (HUNT). International Journal of Behavioral Medicine. June 2014 1;21(3):430-8. Walton DM Elliott JM. A comprehensive model of chronic whiplash-related disorders. Journal of Orthopedics and Sports Physical Therapy. 2017 Jul;47(7):462-71. Pedler A. Pain catastrophic scale. Journal of Physical Therapy. 2010 Jan 1;56(2):137.[26]